Sexual risk behavior in HIV-positive older adults
By Travis I. Lovejoy, PhD, MPH
By 2015, 50 percent of all adults living with HIV/AIDS in the U.S. will be 50-years of age or older (Justice, 2010). The “graying” of persons living with HIV/AIDS is due, in large part, to two factors. First, better clinical care and increasingly efficacious regimens of ART have extended the lives of HIV-positive persons, transforming what was once thought to be a certain death sentence into a chronic, albeit manageable, illness (Porter et al., 2003); as a result, people who were first diagnosed with HIV in their 20s, 30s or 40s are now living into their 50s, 60s and beyond. Second, the proportion of newly-infected persons who are 50-plus years of age has risen in recent years, due primarily to high risk sexual behaviors that account for 90 percent of new HIV infections (Centers for Disease Control and Prevention, 2013). In 2001, an estimated 13 percent of newly HIV-infected individuals in the U.S. were 50-plus years of age (Centers for Disease Control and Prevention, 2007). By 2006, this percentage had risen to 21 percent (an increase of over 60 percent from the 2001 estimate; Centers for Disease Control and Prevention, 2009) and has remained stable at 21-22 percent through 2011, the year for which most recent HIV surveillance data are available from the CDC (Centers for Disease Control and Prevention, 2013). This article will describe sexual risk behavior and its correlates in HIV-positive older adults, review secondary prevention interventions for this population and identify future research priorities for this group.
Continued Sexual Risk Behavior among HIV-Positive Older Adults
Many newly diagnosed HIV-positive persons modify behaviors to reduce the likelihood of onward transmission of HIV (Dombrowski, Harrington, & Goldon, 2013; Fox et al., 2009; Gorbach et al., 2011; Steward et al., 2009). Sexual behavior modifications include the use of condoms, serosorting by which HIV-positive persons engage in unprotected sex only with other HIV-positive persons, the practice of lower HIV transmission risk sexual behaviors, such as oral sex or mutual masturbation with HIV-negative partners, or sexual abstinence (Golub et al., 2010). However, not all newly diagnosed HIV-positive persons entirely eliminate HIV transmission risk behaviors (Fox et al., 2009) and, among those who do, recent data portend a later rebound in sexual risk taking (Gorbach et al., 2011) that stabilizes by 12 months after initial HIV diagnosis (Dombrowski et al., 2013).
Among HIV-positive older adults, estimated rates of unprotected anal and/or vaginal intercourse with HIV-negative or unknown HIV serostatus partners are between 6-30 percent (Coleman & Ball, 2010; Lovejoy et al., 2008; Golub et al., 2010; Cook et al., 2009). HIV-infected older adults who continue to engage in high HIV-transmission risk behaviors tend to be those who use alcohol and drugs (Cook et al., 2006; Cook et al., 2009; Cooperman et al., 2007; Golub et al., 2010), have more psychological symptoms (Golub et al., 2010; Lovejoy et al., 2008), are less knowledgeable about HIV (Lovejoy et al., 2008), use erectile dysfunction medications (Cooperman et al., 2007) and who self-identify as being a man who has sex with men (MSM; Cook et al., 2009; Siegel et al., 2004).
Age-appropriate Secondary Prevention Interventions for Persons Aging with HIV
Few sexual risk reduction interventions have been tailored to meet the unique needs of HIV-positive older adults. These needs include biological and libidinal changes associated with aging, such as menopause in women and erectile dysfunction in men, sexual partnerships with younger partners, survivor guilt over outliving romantic partners and multiple stigmas associated with age, HIV and for some sexual minority status.
To date, findings have been published from two randomized controlled trials that targeted sexual risk behavior in HIV-positive late middle-age and older adults with tailored, age-appropriate interventions. Both interventions were guided by the Information, Motivation, Behavioral Skills (IMB; Fisher & Fisher, 1992) Model. According to the IMB Model, safer sexual behaviors result from increased information about safe sex practices and HIV transmission risks, motivation to use condoms or other means to reduce HIV transmission and the ability to enact safe sex behavior plans (e.g., ability to obtain condoms, use condoms correctly and negotiate condom use with sexual partners). Illa and colleagues (2010) found that a four-session group psychoeducation intervention was superior to usual care in reducing risky sexual behavior in 241 HIV-positive adults 45-plus years of age. Findings were most pronounced for female participants (Echenique et al., 2013). Lovejoy and colleagues (2011) found that, among 100 HIV-positive adults 45-plus years old, four sessions of telephone-administered motivational interviewing (MI) targeting risky sexual behavior reduced total occasions of unprotected anal and vaginal intercourse with all sexual partners and with HIV-negative and unknown HIV serostatus partners, relative to a single telephone-administered MI session and usual care. Findings from these interventions provide preliminary evidence that age-appropriate secondary prevention interventions can reduce sexual risk behavior in HIV-positive older adults.
Although HIV and aging has been identified as a critical area of research and practice for more than a decade, there are still many important gaps to fill in the scientific literature to better inform psychosocial and secondary prevention interventions for persons aging with HIV. First, much of our understanding of the psychosocial and behavioral correlates of sexual behavior in HIV-positive older adults is based on cross-sectional studies. Lim and colleagues (2012) identified longitudinal trajectories and correlates of sexual risk behavior in the form of multiple sexual partners in HIV-positive and HIV-negative older MSM. Additional prospective studies are needed to further characterize patterns of sexual behavior over time in this group, given the dynamic and context-dependent nature of these behaviors. Second, effective secondary prevention interventions that can be delivered in settings HIV-positive older adults frequent for HIV-related services (e.g., AIDS service organizations, HIV medical clinics) are needed. Alternatively, distance technologies (e.g., telephones and videoconferencing) can “transport” interventions to individuals and engage HIV-positive older adults who confront barriers to initiating and maintaining regular face-to-face contact with HIV service providers. However, the extent to which these interventions can be implemented into practice remains an empirical question. Finally, little is known about sexual health of HIV-positive older adults. Secondary prevention interventions for this older adult population should not only aim to reduce sexual risk behavior, but to also improve sexual satisfaction and quality of life.
Centers for Disease Control and Prevention (2007). HIV/AIDS Surveillance Report, 2005 (PDF, 1.80MB). Vol. 17. Published 2007. Accessed April 1, 2013.
Centers for Disease Control and Prevention (2009). HIV/AIDS Surveillance Report, 2007 (PDF, 2.09MB). Vol. 19. Published 2009. Accessed April 1, 2013.
Centers for Disease Control and Prevention (2013). HIV/AIDS Surveillance Report, 2011. Vol. 23. Published February 2013. Accessed April 1, 2013.
Coleman, C. L., & Ball, K. (2010). Sexual diversity and HIV risk among older heterosexual African American males who are seropositive. Applied Nursing Research, 23, 122-129.
Cook, R. L., McGinnis, K. A., Kraemer, K. L., Gordon, A. J., Conigliaro, J., Maisto, S. A.,…, & Justice, A. C. (2006). Intoxication before intercourse and risky sexual behavior in male veterans with and without HIV infection. Medical Care, 44, S31-S36.
Cook, R. L., McGinnis, K. A., Samet, J. H., Fiellin, D. A., Rodriguez-Barradas, M. C., Kraemer, K. L.,, & Justice, A. C. (2009). Erectile dysfunction drug receipt, risky sexual behavior and sexually transmitted diseases in HIV-infected and HIV-uninfected men. Journal of General Internal Medicine, 25, 115-121.
Cooperman, N. A., Arnsten, J. H., & Klein, R. S. (2007). Current sexual activity and risky sexual behavior in older men with or at risk for HIV infection. AIDS Education and Prevention, 19, 321-333.
Dombrowski, J. C., Harrington, R. D., & Golden, M. R. (2013). Evidence for the long-term stability of HIV transmission-associated sexual behavior after HIV diagnosis. Sexually Transmitted Diseases, 40, 41-45.
Echenique, M., Illa, L., Saint-Jean, G., Avellaneda, V. B., Sanchez-Martinez, M., & Eisdorfer, C. (2013). Impact of a secondary prevention intervention among HIV-positive older women. AIDS Care, 25, 443-446.
Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS-risk behavior. Psychological Bulletin, 111, 455-474.
Fox, J., White, P. J., MacDonald, N., Weber, J., McClure, M., Fidler, S., & Ward, H. (2009). Reductions in HIV transmission risk behaviour following diagnosis of primary HIV infection: A cohort of high-risk men who have sex with men. HIV Medicine, 10, 432-438.
Golub, S. A., Tomassilli, J. C., Pantalone, D. W., Brennan, M., Karpiak, S. E., & Parsons, J. T. (2010). Prevalence and correlates of sexual behavior and risk management among HIV-positive adults over 50. Sexually Transmitted Diseases, 37, 615-620.
Gorbach, P. M., Weiss, R. E., Jeffries, R., Javanbakht, M., Drumright, L. N., Daar, E. S., & Little, S. J. (2011). Behaviors of recently HIV-infected men who have sex with men in the year postdiagnosis: Effects of drug use and partner types. Journal of Acquired Immune Deficiency Syndromes, 56, 176-182.
Illa, L., Echenique, M., Saint Jean, G., Bustamante-Avellaneda, V., Metsch, L., Mendez-Muleet, L.,…, & Sanchez-Martinez, M. (2010). Project ROADMAP: Reeducating older adults in maintaining AIDS prevention: A secondary intervention for older HIV-positive adults. AIDS Education and Prevention, 22, 138-147.
Justice, A. C. HIV and aging. Time for a new Paradigm. Current HIV/AIDS Reports, 7, 69-76.
Lim, S. H., Christen, C. L., Marshal, M. P., Stall, R. D., Markovic, N., Kim, K. H., & Silvestre, A. J. (2012). Middle-aged and older men who have sex with men exhibit multiple trajectories with respect to the number of sexual partners. AIDS and Behavior, 16, 590-598.
Lovejoy, T. I., Heckman, T. G., Sikkema, K. J., Hansen, N. B., Kochman, A., Suhr, J. A.,…, & Johnson, C. J. (2008). Patterns and correlates of sexual activity and condom use behavior in persons 50-plus years of age living with HIV/AIDS. AIDS and Behavior, 12, 943-956.
Lovejoy, T. I., Heckman, T. G., Suhr, J. A., Anderson, T., Heckman, B. D., & France, C. R. (2011). Telephone-administered motivational interviewing reduces risky sexual behavior in HIV-positive late middle-age and older adults: A pilot randomized controlled trial. AIDS and Behavior, 15, 1623-1634.
Porter, K., Babiker, A., Bhaskaran, K., Darbyshire, J., Pezzotti, P., Porter, K.,…, & CASCADE Collaboration. (2003). Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet, 362, 1267-1274.
Siegel, K., Schrimshaw, E. W., & Karus, D. (2004). Racial disparities in sexual risk behaviors and drug use among older gay/bisexual and heterosexual men living with HIV/AIDS. Journal of the National Medical Association, 96, 215-223.
Steward, W. T., Remien, R. H., Higgins, J. A., Dubrow, R., Pinkerton, S. D., Sikkema, K. J.,…, & Morin, S. F. (2009). Behavior change following diagnosis with acute/early HIV infection—A move to serosorting with other HIV-infected individuals. The NIMH Multisite Acute HIV Infection Study: III. AIDS and Behavior, 13, 1054-1060.
About the Author
Travis I. Lovejoy, PhD, MPH, is assistant professor of psychiatry at Oregon Health & Science University and a health and addictions psychologist at the Portland VA Medical Center. Lovejoy is an HIV/AIDS mental health trainer through the HIV Office for Psychology Education of the American Psychological Association. His research examines secondary prevention of HIV infection and models of collaborative and integrative care to manage chronic illnesses. His clinical work intersects addictions therapy and management of chronic co-morbid medical and mental health conditions.